CAPS staff increased unrelated to suicides, admins say

Wait times may not go down in the long term, despite increase in staff

F o llowing the fifth student suicide in 12 months, the University announced in February that it would create new permanent clinical positions at Counseling and Psychological Services for this fall, a move that administrators say likely would have occurred even without the student deaths.

CAPS has come under scrutiny this semester after two undergraduates committed suicide several weeks apart. Much of the dialogue has focused on long wait times to schedule an appointment at CAPS, a function of high demand for its services. In February, the University established a commission to study student mental health at Penn.

In an email sent to students and parents on Feb. 6, high-level administrators announced that CAPS would hire several new staffers to meet the increased student need. While the announcement was expedited by several weeks due to increased mental health concerns, administrators said the budget request for more counselors was already submitted and was expected to be approved later this semester as part of the University’s tendency to adjust CAPS’ services over time.

Opening up positions

Even though Penn announced the new hires shortly following student suicides this semester, the changes have been in the works for many months.

Each year, the budgeting process for CAPS begins in September with the Budget Steering Committee , a group that includes Penn President Amy Gutmann and Provost Vince Price . The committee plans for the upcoming fiscal year, which begins on July 1 and ends June 30. It divides up the money in the general fee — the “fees” in “tuition and fees” — to organizations like the Division of Public Safety, the Annenberg Center and the Division of the Vice Provost for University Life, which CAPS operated under.

“Before the student deaths happened, because the budget process started a long time ago, we had in the budget a request for additional funds for additional counselors,” Associate Vice Provost for University Life Max King said. “Part of that is reflected in the University’s announcement that they are committing more money.”

Since the 2006 fiscal year — not including the new positions for the fall — Penn has increased its funding for CAPS by 82 percent, with an average annual growth rate of 7.8 percent per year, according to records kept by Bonnie Gibson, Penn’s vice president of budget and management analysis. This includes 11 new full-time professionals, two part-time professionals and one post-doctoral position. In comparison, since the 2006 fiscal year, the average amount of funding for divisions that receive money from the general fee has increased by 17 percent over the same time period, or 2 percent per year.

Gibson declined to provide more specific information, including the amount of money CAPS receives in absolute terms.

Prior to the most recent hires, the last request was made for the 2012 fiscal year, when Penn provided CAPS with funding for four more staff members.

CAPS’ budgeting process starts every year when Director of CAPS Bill Alexander sends King a breakdown of the expected cost of running CAPS during the next fiscal year, which they discuss before sending the proposal to the Budget Steering Committee for approval.

“CAPS is under the microscope in this process,” Alexander said. “We are very poked and prodded.”

VPUL looks at the number of students who visit CAPS to determine whether additional counselors are needed, King said. The close scrutiny of CAPS is part of VPUL’s increasing trend to make its departments accountable for the work that they do, Alexander said.

“It was easy for CAPS because as psychologists and social workers, we’re measuring our work all the time anyway,” Alexander said. CAPS has a depression screening measure and an outcome questionnaire to assess the severity of students’ symptoms and their progress in treatment. This information is aggregated and sent to VPUL in monthly reports.

CAPS’ monthly reports also include data on the demographic information of students who visit CAPS and the number of students seeing counselors, Alexander said. The Steering Committee reviews the information when it decides whether or not to pay for new CAPS staff, which helps weigh CAPS’ requests against the requests from other departments. The detailed information that CAPS provides for the Budget Steering Committee is more extensive than what other departments provide, Gibson said.

VPUL declined to provide any of CAPS’ monthly reports for the article.

“If they have a request, we need to know the justification for that request,” Gibson said. “We hear everybody’s requests and then we look at what resources are available and which requests are the top priorities. In any given year, there are requests that are funded and requests that are turned down.”

In the case of CAPS, however, Alexander and King couldn’t recall any requests for additional CAPS staff that had ever been turned down. CAPS has increased its staff every two or three years for the past 10 years, according to Alexander.

“It’s clear that more and more of our students use CAPS’ services — that’s the reason that they have tended to be funded,” Gibson said. “If they said to us, ‘Well, we’re not seeing any increase in demand but we’d like to add more people anyway,’ they probably would not get those resources.”

The staff members at CAPS vary widely in expertise and cost — they include social workers, psychiatrists, clinical psychologists, doctoral students and receptionists. Psychiatry positions are the most expensive to pay for, while receptionist positions are relatively inexpensive.

In the fall, CAPS will hire either three or four new professional counselors, depending on the cost. This year, though, Penn announced its budget decision in February rather than the typical mid- to late-March due to the recent student suicides.

“We know that the needs of the community are placing greater than ever demand on our valuable student support teams,” the Feb. 6 email from Gutmann, Price and Executive Vice President Craig Carnaroli said. “As a result, we are taking immediate steps to expand our mental health efforts and to ensure that we are doing everything possible to reach and support students in distress.”

Gutmann declined to discuss the specifics of the CAPS hiring decision, instead deferring to the Provost’s Office. The Provost’s Office, in turn, declined an interview request, deferring to Gibson.

“The decision was made earlier to allow CAPS to move faster on the interviewing and hiring people,” Gibson said.

Still, Alexander expected that Penn would have chosen to provide the counseling positions even without the student deaths, just in an announcement a few weeks later.

The tradeoff

Even when new counselors are hired, students may still face a substantial wait time to get an initial appointment.

There’s a tradeoff: CAPS’ capacity to take on more students increases, but more students also request appointments — so the wait time doesn’t decrease significantly, Alexander said.

The wait time at CAPS has grown over the years due to a gradual increase in demand for CAPS’ services, Alexander added, which is why CAPS requests new counselors so frequently. Even when the new counselors cut down the wait time initially, it soon starts to rise again as more people request appointments. CAPS is currently at the highest demand in its history.

The average wait time in fiscal year 2013 was 13.2 days, Alexander said in a January interview. However, The Daily Pennsylvanian reported last week that some students have had to wait over five weeks for an initial appointment.

The new CAPS positions created in 2012 followed backlash from students on the significant growth of wait times since 2008, when a budget freeze kept CAPS from hiring any more counselors. For the 2012 hires, CAPS sent more extensive information on wait times to VPUL than usual, and Penn made the new positions that year specifically to help cut down the wait, Gibson said.

“If there is growth in the number of people you are serving, and if adding additional resources would make that easier and better for students, then that’s what we’re going to do,” Gibson said.

At some point, CAPS will have enough staff to fulfill the entire demand for services. But CAPS has yet to reach that “saturation point,” so when it adds counselors, more students request appointments.

Any estimate of when the University will reach that point would be “pure speculation,” Alexander said.

At peer institutions — Ivy League universities and other schools similar to Penn — the saturation point is somewhere between 18 and 22 percent of the student body, according to Alexander. Last year, CAPS saw at least 13 percent of the student body, and this year it expects to see at least 15 percent with the new counselors.

In 2006, CAPS served 9.5 percent of the student population, compared to 13 percent in 2011. The percentage rose in part because of the addition of new counselors in 2008 who could take on more patients, according to a 2011 DP article.

Penn currently has about 600 students per staff member at CAPS, according to the CAPS staff directory website, ranking fifth-best in the Ivy League in terms of student-to-staff ratio. According to information on the websites of the other Ivy League counseling centers, the average number of students per staff member is around 550. Yale has the lowest ratio, at around 215 students per staff member, and Harvard has the largest ratio, at around 880 students per staff member.

Although other university counseling centers have been able to reach their saturation points, Alexander said, that doesn’t necessarily mean that they have more counselors or more support from their universities. Instead, some schools put a cap on the number of sessions for each student before referring them to an outside provider — a practice that Alexander said CAPS rejects.

In at least some cases, however, there are questions about how rigorously CAPS follows that policy. In the 2011 fiscal year, 54 percent of patients attended between one and five therapy sessions, and only 9 percent of CAPS clients attended more than 25 sessions, according to the 2011 DP article.

Case notes provided to the DP by Nick Garg — a former CAPS psychiatrist who was fired in 2012 — describe an undergraduate who visited CAPS in the September of 2011. She had been previously diagnosed with depression and bipolar disorder and initially agreed with the psychology trainee working on her case to go through short-term treatment, the notes read.

During a “traumatic” winter break, she sought out her previous therapist for help, who advised that she stop seeing CAPS because “she always felt pushed out of CAPS,” according to the notes.

With new counselors beginning in the fall, CAPS could add a permanent increase of 15 more sessions a week — but the initial dent in the wait time from the new hires could rise again, meaning CAPS still might need to request for more counselors.

“It’s the chicken and the egg — if you build it, they will come,” Alexander said. “But not forever.”

Splitting staff

Most of the money that CAPS receives from the Steering Committee goes to salaries for staff members. But not all of each counselor’s efforts are devoted to counseling, which also makes it more difficult to reduce the wait time.

CAPS recommends that counselors devote at least 65 percent of their time to seeing patients — the rest can be devoted to clinical work or to work done outside of the office as part of CAPS’ outreach and prevention services. The outreach and prevention work involves meeting with student groups and professors to educate them on the resources available at CAPS, how to identify signs of depression and who to turn to if someone needs help.

“One of our biggest challenges is just the decentralized nature of this campus. It’s so hard to get access to students,” Meeta Kumar, director of outreach and prevention at CAPS, said.

CAPS works to solve this problem in part through its liaison program, which links CAPS workers to about 80 liaisons — like professors and assistants in the Weingarten Learning Resources Center — who engage with students in different ways.

“One thing that students don’t know we do is we consult with faculty and staff a lot,” Alexander said. “When they are wondering, ‘I think I have a student in my class who might be depressed, but I don’t know how to talk to the student,’ they call us all the time. They say, ‘Can you come talk to us about how to manage a student we’re worried about?’”

However, some students have spoken about a lack of communication between CAPS and other departments.

“It kind of seemed like every department was separate to me,” said Rachel, a College junior who requested her name be changed for confidentiality reasons.

In the spring of 2013, Rachel went to CAPS when she developed depression after the death of her grandfather. CAPS recommended that Rachel speak to her academic advisor because her depression was affecting her schoolwork. When she contacted her advisor, she was told that advisors don’t communicate with professors on behalf of students. The advisor recommended she go to Weingarten for more help with her academics, Rachel said.

“So I went to Weingarten, and they didn’t know what to do with the situation,” she said. Weingarten referred Rachel back to CAPS, where she was already seeing a counselor. “I don’t think they get many depressed students who need help,” she said.

Rachel never went back to Weingarten after her first meeting. She decided to stay at CAPS until she felt better a few months later, and her grades eventually picked up, she said.

Similar to Rachel’s experience with Weingarten, referrals to CAPS by liaisons are common, Alexander said.

The liaison program and other CAPS outreach initiatives allow CAPS to reach more students in need, meaning the demand for its clinical services continues to grow, Kumar, the outreach director, said.

“In theory it sounds like yes, maybe we want you to carve out some time and make yourself available for outreach activities, but once you take on X number of clients, you’re just booked for those hours in a week,” Kumar said. “And for many staff who are doing outreach there’s a little bit of a double whammy because once you’re out there ... you then end up bringing many of those students over as your clients.”

CAPS measures the satisfaction and efficacy of its outreach initiatives and its clinical work and sends the data to VPUL, so administrators can see how CAPS uses its money and how effective its efforts are before deciding the next year’s budget.

“Obviously this year CAPS is doing a lot of outreach,” King, the associate vice provost at VPUL , said. “Every day they are going to various student groups, to departments, to the college houses — they’re meeting with different groups and working with them to try and process people’s reactions to the campus climate right now.”

CAPS refers to these efforts as “postventions,” which follow times of high stress on campus. Most of the efforts happen on nights and weekends, when student groups meet.

“In the last few months, everyone’s just been incredibly stretched,” Kumar said.

Before Penn ultimately decided to hire new counselors for the fall, CAPS received money for three temporary counseling positions for the rest of the school year to help with outreach initiatives, Alexander said. Since CAPS did not receive money from the general fee for these temporary positions — because it was not expecting to hire these counselors — VPUL paid for them with its reserve of undesignated funds, which it can use throughout the school year at its discretion.

“We keep some money in a reserve pool because things happen during the year, and so when we saw a need for getting some additional counseling ability at CAPS right away, we were able to free up money,” King said.

When CAPS hired the temporary counselors, Alexander said, the wait time instantly dropped to three days from the usual two to three weeks. But it will rise as the counselors fill their time slots with students in need.

“Day to day, year to year, we look at this stuff,” King said. “Here’s that big pile of requests, and here’s that not as big pile of money, and we have to make decisions.”